Tuesday, 21 July 2009


"Explosion in NearTown, persons reported." I grab my watch and stare, bleary-eyed at the time: 03.30. I'm in the car in minutes, and I shake my head, trying to clear the last vestiges of sleep from my mind.

It's an easy journey, and my thoughts go to the management of severe burns. The priorities are still the same; airway, breathing and circulation; but in this case they take on a whole new meaning. Very often with a severe burn there is swelling of the soft tissues of the neck and throat, making the airway close up alarmingly quickly. I will need to look for evidence of inhalational injury, and act accordingly, rather than waiting for something to develop. Similarly, the lungs can be badly damaged by the smoke and the heat, and the patient can deteriorate very rapidly. As far as circulation is concerned, burn victims lose a large amount of fluid, both from the initial burn and from the exposed flesh, leading to severe dehydration and low blood pressure. They need lots of fluid replaced. However, those damaged lungs will not tolerate much fluid given to a patient, and will leak plasma into the air spaces if too much is infused. It's a very fine line to be tread.

And that's not including the management of the burn itself. Learning which dressings to use when is a whole career in itself.

I arrive on scene. I know I am there because of the vast number of fire tenders, all parked across the road, in the road, on the pavement. Oh well, it's on foot from here.

As I make my way slowly through the emergency vehicles, managing, on 3 separate occasions, not to trip over a fire hose, I am greeted with an increasing amount of debris. A chair. A filing cabinet, strangely mishapen. Half a table, its corners burnt. And then, as I approach the building, there is just a space. A gap between two other buildings, filled with rubble. The roof tiles are strewn across a huge area. I wonder why I have been called. Surely, no-one could have survived this.

I am directed to an ambulance. I open the door and enter, heavy hearted. My one fear, bordering on phobia, is that of being involved in a house fire. So many times I have been presented with men and women, occasionally children too, who had no chance of survival.

This man is talking. He apparently had come home, to his flat above a newsagents, and switched on the light. At which point, he tells me, his world exploded. When the fire crews arrived, he was sitting on what was left of the stairs, headin his hands, wondering what had happened.

He's not unharmed, far from it. I make a rapid assessment: He is talking, but his voice is hoarse and he has singed nasal hairs. He's going to need intubating some time soon. His chest is clear, with only a few wheezes. He has a good pulse and blood pressure. His burns are quite extensive - about 30% estimated. He will need to go to a specialist unit to have them properly treated. My mind shifts to an email I received from our regional burns centre, stating that they would no longer accept any direct referrals from the roadside, and that these cases need to go to the local hospital first to be stabilised. Good, that's one decision out of my hands...

So, do I tube him here, or get him to the nearest local, about 15 minutes away. I think back to my last post, when I took an unintubated patient to the very same hospital, expecting an immediate response, only to get ticked off when they did nothing. So, that's another decision made: he's being tubed here.

I am always very worried when I tube a burns victim. I have no idea until I have a look with the laryngoscope how much swelling has already occurred. There is always the possibility that the windpipe is so narrowed that it will be nigh on impossible to get a tube in place. I prepare the standard drug cocktail, and open my emergency airways pack. This is a set of instruments designed for me to make a hole in the patient's neck, and pass a tube directly into the windpipe. Never done one yet, but I'm not going to be caught out.

I give the drugs, take a deep breath, and pass the laryngoscope in to his mouth, sweeping the tongue over to the left, to give me a view of .... the cords!!! Yippeee! I can't describe the relief I get when I see the glistening white of the vocal cords, with the windpipe visible as a dark tunnel. These cords are not so glistening: there is a fine coating of soot, and this tells me that, had I not tubed him there and then, the journey to the hospital would have been a whole different ball game...

Tubed, ventilated, packaged. We call in the job, and drive to the local A&E Department.

After we finish the necessary paparwork, tea and debrief, the crew drive me back to the scene. It is daylight now, and we stand there, wondering how anyone could have survived such a devastating blast.

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